Medical Care最新文献

{"title":"Hepatitis C Virus Cascade of Care in Florida Emergency Departments.","authors":"Pilar Hernandez-Con, Suk-Chan Jang, Steven M Smith, Chanakan Jenjai, Faheem Guirgis, Michael C Petrauskis, Christine Gage, Haesuk Park","doi":"10.1097/MLR.0000000000002354","DOIUrl":"10.1097/MLR.0000000000002354","url":null,"abstract":"<p><strong>Background: </strong>Florida has the second-highest rate of acute hepatitis C virus (HCV) infection cases in the United States. However, HCV care cascade outcomes among individuals seeking care in Florida emergency departments (EDs) remain unknown.</p><p><strong>Objectives: </strong>To assess HCV care cascade outcomes and identify HCV infection predictors among individuals tested for HCV in Florida EDs.</p><p><strong>Research study design: </strong>This retrospective study used electronic health records (2016-2023) linked to the Agency for Healthcare Research and Quality on Social Determinants of Health regional data.</p><p><strong>Subjects: </strong>Adults aged 18-79 years tested for HCV infection in Florida EDs.</p><p><strong>Measures: </strong>Outcomes included the proportions of individuals completing each HCV care cascade step: (1) HCV screening; (2) HCV diagnosis; (3) linkage to care; and (4) treatment initiation. A multivariable logistic regression model was used to identify predictors of HCV infection.</p><p><strong>Results: </strong>Among individuals seeking care in EDs, 4.98% (n=18,444) were tested for HCV, of whom 4.97% were confirmed HCV-positive. Among HCV-positive individuals, 11.24% were linked to care, and 2.84% initiated treatment. Significant predictors of HCV infection included having Medicaid insurance (OR=1.53, 95% CI: 1.14-2.07) or being uninsured (OR=2.88, 95% CI: 2.02-4.12), coinfection with human immunodeficiency virus (OR=28.99, 95% CI: 22.31-37.67), opioid injection drug use (OR=3.62, 95% CI: 2.76-4.75), opioid overdose (OR=3.89, 95% CI: 2.32-6.52), and residing in communities characterized by lower educational attainment (fourth quartile OR=1.95, 95% CI: 1.27-2.98).</p><p><strong>Conclusions: </strong>Significant gaps persist across the HCV care cascade among individuals tested in Florida EDs. Innovative public health interventions are needed to support these vulnerable populations.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"592-600"},"PeriodicalIF":1.9,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148352357","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Impact of an Oncology Hospital at Home Program on Health Care Costs.","authors":"Richard E Nelson, Brock O'Neil, Anne C Kirchhoff, Jared Huber, Minkyoung Yoo, Kathi Mooney","doi":"10.1097/MLR.0000000000002347","DOIUrl":"10.1097/MLR.0000000000002347","url":null,"abstract":"<p><strong>Introduction: </strong>Hospital-at-home is an initiative to move health care services that have traditionally been provided in a hospital setting to a patient's home. The objective of this study was to assess the impact of the oncology Huntsman at Home (HH) hospital-at-home program on health care costs from the health care system's perspective.</p><p><strong>Methods: </strong>Using a difference-in-difference approach, we compared health care costs between 169 oncology patients enrolled in HH and 198 similar patients who would have been eligible for HH but lived outside the HH service area. Costs were measured from the health system perspective using an innovative cost-accounting tool. We constructed longitudinal datasets spanning the 2 patient-quarters before enrollment and the 2 patient-quarters following an acute episode. Outcomes were total direct medical costs of health care encounters as well as subcategories of cost, including facility, imaging, supplies, pharmacy, labs, and other. We ran fixed effects linear regression models to assess the impact of HH on health care cost outcomes.</p><p><strong>Results: </strong>We found that HH was associated with a statistically significant reduction in cost for the 6 months post-admission (total -$8,337, P =0.012) and the first quarter post-admission (-$10,516, P =0.009), with significant reductions in pharmacy, facility, and other costs. We also examined a subset of patients with gastrointestinal or gynecologic cancers as exemplars of patients at considerable risk for extended complications and found similar cost reductions 6 months (-$8006, P =0.006) and in the first quarter (-$10,438, P =0.004).</p><p><strong>Conclusion: </strong>We found that an oncology hospital at home lowers health care costs, particularly during the 3 months following a care episode.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"559-565"},"PeriodicalIF":1.9,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148283908","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Veteran Satisfaction With Lung Cancer Screening Care: A Cross-Sectional Evaluation.","authors":"Jennifer A Lewis, Amber J Hackstadt, Kathryn D Snyder, Lauren R Samuels, Daniel Park, Robert Winter, Jacquelyn Pennings, Carolyn Audet, Sally J York, Fred Hendler, Claudia I Henschke, David F Yankelevitz, Drew Moghanaki, Robert S Dittus, Michael E Matheny, Hilary A Tindle, Christianne L Roumie, Lucy B Spalluto","doi":"10.1097/MLR.0000000000002355","DOIUrl":"10.1097/MLR.0000000000002355","url":null,"abstract":"<p><strong>Objective: </strong>To assess differences in lung cancer screening care satisfaction among Veterans residing in rural and nonrural areas.</p><p><strong>Methods: </strong>We identified Veterans screened for lung cancer from 2018-2021 at 10 Veterans Affairs Medical Centers and surveyed a sample using an adapted version of the Patient Satisfaction with Cancer Care (PSCC) scale. The primary analysis ( t test) evaluated the association between rurality and care satisfaction in responder and population-weighted cohorts. Secondary analysis (linear regression) estimated the association of age, sex, race, ethnicity, smoking status, education attainment, and facility location with care satisfaction. The Fisher exact test evaluated the association of rurality and smoking status with individual PSCC item agreement.</p><p><strong>Results: </strong>The response rate was 36.0% (n=689 complete surveys). The mean responder age was 68.3 years; 95.4% were male; 50.2% rural; 55.6% currently smoking. There was no significant difference in care satisfaction by rurality in the responder cohort [mean PSCC score 72.4 ( SD =14.2), rural 72.4, non-rural 72.4, P =0.99] or population-weighted cohort [mean PSCC score 71.9 ( SD =14.2), rural 72.1, non-rural 71.9, P =0.81]. \"Currently smoking\" status was negatively associated with care satisfaction [coefficient=-3.20 (-6.42,0.02)]. Individual PSCC items with the highest and lowest agreement were \"I felt that I was treated with courtesy and respect\" (93.6% agree); \"I knew what the next step in my care would be\" (65.2% agree).</p><p><strong>Conclusions: </strong>Veterans in rural and nonrural areas reported similar levels of satisfaction with lung cancer screening care. Veterans who currently smoke reported lower levels of satisfaction. Veterans identified limited understanding of lung cancer screening processes and poor communication as areas needing improvement.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"601-610"},"PeriodicalIF":1.9,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13456552/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148412173","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Community Health Workers in the Veterans Administration: Exploring Opportunities and Barriers to Integration for Rural and Caregiver Populations.","authors":"Katlin Harker, Teresa Howard, Battista Smith, Sandro Pinheiro, Nathan A Boucher","doi":"10.1097/MLR.0000000000002352","DOIUrl":"10.1097/MLR.0000000000002352","url":null,"abstract":"<p><strong>Background: </strong>Rural Veterans and caregivers face challenges related to health care access, care coordination, and institutional trust-areas where Community Health Workers (CHWs) are well positioned to make an impact. Despite their potential, CHW integration into complex federal systems such as the US Department of Veterans Affairs (VA) remains limited. CHWs represent a promising strategy to enhance access and care continuity for rural Veterans and caregivers.</p><p><strong>Objectives: </strong>To examine perceptions of community and institutional partners regarding integration of CHWs into the VA to support rural Veterans and their family caregivers.</p><p><strong>Methods: </strong>We conducted virtual, semistructured interviews with 24 key informants from community organizations and VA-affiliated institutions (October 2024 to February 2025). Interviews explored key informant views on CHW roles, responsibilities, training needs, and implementation considerations. A community advisory board of CHWs guided all aspects of the project.</p><p><strong>Results: </strong>Four themes emerged: (1) CHW scope of work, (2) barriers and facilitators to CHW implementation, (3) CHW support needs, and (4) training and requisite knowledge.</p><p><strong>Conclusions: </strong>Effective CHW integration into the VA will require role clarity, robust support systems, and context-specific training tailored to this population. To ensure sustainability, VA leadership will need to standardize role definitions across clinical and community domains. A strong business case-demonstrating improved care coordination, reduced emergency department use, and enhanced screening for social determinants of health-will be critical to secure funding and supportive policy. CHW integration could also offset staff burden within the VA.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"611-622"},"PeriodicalIF":1.9,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148405144","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Hospital-Physician Integration and Differences in the Use of Orthopedic Care Across Race and Ethnicity.","authors":"Brady Post, Pabitra Chowhury, Alexandra Harris, Farbod Alinezhad, Winston Kennedy, Nasim Ferdows, Gary J Young","doi":"10.1097/MLR.0000000000002326","DOIUrl":"10.1097/MLR.0000000000002326","url":null,"abstract":"<p><strong>Objectives: </strong>To determine if hospital-orthopedist integration is associated with larger or smaller race and ethnicity gaps in the utilization of total knee arthroplasty (knee replacement) and physical therapy among Medicare beneficiaries.</p><p><strong>Data sources and study setting: </strong>Inpatient and outpatient Medicare claims data from 2015 to 2021.</p><p><strong>Study design: </strong>Retrospective study of patients newly diagnosed with osteoarthritis. We compared utilization among patients of hospital-integrated orthopedists and independent orthopedists.</p><p><strong>Principal findings: </strong>A total of 18% of patients received knee replacements, and 32% received physical therapy within 12 months of an initial osteoarthritis diagnosis. Black patients were less likely to receive knee replacements (-6.6 percentage points, 95% CI: -7.6 to -5.6) and physical therapy (-9.3, 95% CI: -10.5 to -8.0) than White patients. Hispanic patients' likelihood of knee replacements and physical therapy was not statistically different from that of White patients. Hospital-orthopedist integration was not associated with receipt of knee replacements but was negatively associated with receipt of physical therapy (-9.5 percentage points, 95% CI: -10.1 to -8.8). Race/ethnicity differences persisted across practice settings: the interaction between orthopedist integration status and race/ethnicity did not affect the likelihood of receiving knee replacements or physical therapy.</p><p><strong>Conclusions: </strong>Disparities persisted across both hospital-integrated and independent settings for Black patients. As large integrated health systems become dominant, policymakers may need to create incentives that harness their strengths to close care gaps.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"553-558"},"PeriodicalIF":1.9,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13573659/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148330943","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Erratum: Hospital Performance on Hospital Consumer Assessment of Healthcare Providers and System Ratings Associations With Nursing Factors.","authors":"","doi":"10.1097/MLR.0000000000002357","DOIUrl":"10.1097/MLR.0000000000002357","url":null,"abstract":"","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"635-636"},"PeriodicalIF":1.9,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148471609","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Associations Between Social Drivers of Health and Intervention Reach During Implementation of a Supervised Walking Program.","authors":"Sarah M Wilson, Akanksha Das, Kaileigh Byrd, Caitlin B Kappler, Karen M Stechuchak, Greeshma Thomas, Tiff A Beaver, Maren K Olsen, Kimberly S Johnson, Courtney Van Houtven, Susan N Hastings","doi":"10.1097/MLR.0000000000002353","DOIUrl":"10.1097/MLR.0000000000002353","url":null,"abstract":"<p><strong>Objective: </strong>To examine associations between social drivers of health and veteran-level reach of STRIDE, a supervised walking program implemented in the Veterans Health Administration (VA).</p><p><strong>Study setting and design: </strong>We included 2527 patients across 5 facilities. We tested whether housing insecurity, rurality, race, and neighborhood deprivation were associated with reach, defined as any STRIDE walk during hospitalization.</p><p><strong>Data sources and analytical sample: </strong>We used the first 6 months of postimplementation data from a stepped-wedge implementation trial.</p><p><strong>Principal findings: </strong>During the implementation period, 197 veterans (7.8%) received at least 1 STRIDE walk. In unadjusted models, patients residing rurally (vs. urban) and those who were White, non-Hispanic/Latino (NH) (vs. Black NH) were significantly more likely to receive ≥1 STRIDE walk. Unadjusted models showed large site differences in STRIDE reach, ranging from 3% to 26% probability by site. Reach differences coincided somewhat with facility-level racial composition: the lowest reach was observed at a site with a majority of Black NH admitted patients, whereas the highest reach was found at a site with a majority of White NH patients. In adjusted models, patient-level rurality remained associated with greater reach (probability 9% for rural veterans vs. 6% for urban veterans), but race was no longer associated (probability 6% among White NH veterans vs. 7% among Black NH veterans).</p><p><strong>Conclusions: </strong>Patient-level rurality was consistently positively associated with implementation outcomes. Patient-level race was associated with implementation outcomes in unadjusted but not adjusted models. Secondary analyses in implementation trials may help assess how social drivers of health are associated with implementation outcomes.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"623-631"},"PeriodicalIF":1.9,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13456543/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148669831","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"In the Shadows: Health Utilization Outcomes Among Black Undocumented Immigrants.","authors":"Joseph Nwadiuko, Arrianna Marie Planey, Naomi Zewde, Arturo Vargas Bustamante","doi":"10.1097/MLR.0000000000002346","DOIUrl":"10.1097/MLR.0000000000002346","url":null,"abstract":"<p><strong>Introduction: </strong>Black undocumented immigrants face dual barriers to care access based on their legal status and due to structural racism in US society. Prior work has shown that Black immigrants (and particularly undocumented immigrants) are less likely to be insured than the general population. However, less is known about other dimensions of health care access for Black undocumented immigrants.</p><p><strong>Methods: </strong>This study analyzes nationally representative data from the National Health Interview Survey (NHIS) from 1999 to 2018 to examine health care access and outcomes along the axes of legal status (undocumented, documented, naturalized citizen, and US-born citizen) among Black individuals aged 40 and above. We analyzed clinician visits over the past 2 years and overnight hospitalizations over the past year (the latter for individuals aged 40 y and older). Non-Hispanic White US-born citizens (NHWC) were used as the reference category.</p><p><strong>Results: </strong>Among Black individuals across legal strata, Black undocumented immigrants had higher odds of uninsurance (OR: 4.7 95% CI: 3.6, 6.0), having no recent physician encounters in the previous 2 years (OR: 1.7; 95% CI: 1.2, 2.3), including lower odds of emergency room visits (OR: 0.7, 95% CI: 0.5, 0.9) and overnight hospital visits (OR: 0.5; 95% CI: 0.4, 0.7) in the past year. They also had lower odds of any blood pressure measurements (OR: 0.5; 95% CI: 0.38, 0.77) in the past year, and women aged 40 had lower odds of ever having received cervical cancer screening (OR: 0.1; 95% CI: 0.1, 0.2). Across all categories, utilization decreased with less secure legal status. Causal mediation analysis showed that insurance status played an important role in the relationship between undocumented status and having had a recent physician visit, mediating 2.7 (95% CI: 1.2%, 4.0%) of the 5.1-point gap (95% CI: 1.7%, 8.7%) between Black undocumented adults and NHWC.</p><p><strong>Conclusions: </strong>The relationship between race and legal status is complex. Legal status is significantly associated with access to insurance and outpatient care among Black immigrants.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"585-591"},"PeriodicalIF":1.9,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148252224","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Where Are They Now: Analysis of 10- and 20-Year Cohorts of Homeless Veterans Served by the Veterans Affairs Health Care System.","authors":"Jack Tsai, Dorota Szymkowiak","doi":"10.1097/MLR.0000000000002350","DOIUrl":"10.1097/MLR.0000000000002350","url":null,"abstract":"<p><strong>Background: </strong>The U.S. Department of Veterans Affairs (VA) has invested billions of dollars to address homelessness, but there has been limited analysis of long-term outcomes.</p><p><strong>Objectives: </strong>This retrospective study followed 2 cohorts of homeless veterans over 2 decades to identify long-term trajectories and predictors of mortality and continued VA homeless program use.</p><p><strong>Research design: </strong>National VA administrative data were analyzed from 2004 to 2024.</p><p><strong>Subjects: </strong>A 2004 cohort of 85,533 homeless veterans and a 2014 cohort of 222,974 homeless veterans.</p><p><strong>Measures: </strong>Primary outcomes were mortality and continued use of VA homeless programs.</p><p><strong>Results: </strong>A total of 50% of the first cohort died within 20 years (mean=63.9 y old) and about one-quarter of the second cohort died within 10 years (mean=65.3 y old). Of surviving veterans, 25% in both cohorts used VA homeless programs, and 32%-36% used VA emergency department/urgent care in 2024. In both cohorts, predictors of mortality included being older, non-Hispanic White, male, having medical comorbidities, and alcohol use disorder. Predictors of continued use of VA homeless programs included non-Hispanic Black, male, unmarried, low-enrollment priority group, military sexual trauma, and drug use disorder. In both cohorts, 61%-81% with substance use disorders received substance use treatment, but generally of short duration.</p><p><strong>Conclusions: </strong>In a homeless population with access to comprehensive health care, there is a long-term need to address premature mortality, substance use disorders, and pathways to independence. These findings signal the work that remains in the VA, and the broader challenges that may lie ahead in other national efforts to address homelessness.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"566-576"},"PeriodicalIF":1.9,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148205288","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Response to \"Temporal Misalignment and Selection Bias in Burn Pit Smoke Exposure and Sleep Apnea in US Veterans\".","authors":"Drew A Helmer, Javad Razjouyan, Amir Sharafkhaneh","doi":"10.1097/MLR.0000000000002349","DOIUrl":"10.1097/MLR.0000000000002349","url":null,"abstract":"","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"632-634"},"PeriodicalIF":1.9,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148579293","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}